Inviscision: A Futuristic Alternative to Endaural Incision for TMJ Surgeries.

Background: As TMJ surgery incisions have evolved, there has been a decrease in facial deformity and adequate surgical access. Even though the traditional preauricular and endaural incisions offer great exposure, they heal with a noticeable scar; in contrast, the Inviscision becomes invisible. Aim: To compare and evaluate both the approaches for TMJ surgeries in terms of surgical exposure, VII nerve injury and postoperative aesthetics. Methods: 60 TMJ surgery cases were randomly divided into two groups: Group A-30 Inviscision and Group B-30 Endaural incision and assessed for the amount of time from the incision to the exposure, ample access for surgery and postoperative nerve injury, scarring, cartilage injury/necrosis and ear deformity. All the patients were followed up for an average of six months. Results: Surgical exposure time was average 12 and 10 min via Inviscision and endaural incision, respectively. In Inviscision, scar becomes invisible after 40 days and in endaural incision, scar becomes a thin but visible line after 35 days. No cases of hypertrophic scar, keloid formation, cartilage injury/necrosis/ear deformity in either group. Transient temporal branch of VII nerve weakness seen in 33% of Inviscision and 40% of endaural cases which improved after average 3 and 3.4 months, respectively. Likert's patient satisfaction score was average 4 and 2, and POSAS score for scarring was 1.5 and 3, in Inviscision and endaural incision, respectively. Conclusion: Inviscision gives adequate exposure, avoids all related anatomic structures, other than causing transient retraction neuropraxia, along with outstanding aesthetic outcomes by hiding the scar in the anatomical folds of the ear auricle. Although, endaural incision provides better surgical time management and equivalent surgical exposure, Inviscision proves to be a better alternative for TMJ surgeries through all other parameters.

Abdominal Dermal Fat Graft Versus Nasolabial Flap in Oral Submucous Fibrosis: A Randomized Clinical Trial.

Introduction: A prospective study was conducted to find out an effective alternative in the form of non-vascularized abdominal dermal fat graft (ADFG) and to compare its efficacy with the vascularised nasolabial flap (NLF) for the treatment of oral submucous fibrosis (OSMF). Method: Comparative study comprising of 30 patients with Grade 3 and 4A OSMF, randomly divided into 2 groups: Group A (ADFG) and Group B (NLF). They were evaluated for mouth opening (MO), graft uptake, time taken for mucosalization, pain, intercommissure distance (ICD), scar, duration of surgery (DOS), patient satisfaction and thickness of masseter muscle on ultrasonography. Findings: At 6 months, MO improved by 22.4 and 36.2 mm in Group A and Group B, respectively. There was statistically significant difference (p < 0.05) seen for the values between the groups for all the parameters except for ICD and VAS score, which was statistically insignificant (p > 0.05). Intraoral hair growth, facial scar, orocutaneous fistula and commissure tear was seen in Group B. Complete necrosis of graft followed by recurrence was seen in three cases in Group A. Conclusion: NLF holds better as compared to ADFG in the management of OSMF. However, the cornerstone of success remains habit cessation and aggressive physiotherapy. The limitations of the study are small sample size and short duration of follow-up.

Comparison of three different approaches in treatment of mandibular condylar fractures - Our experience.

Background: The principal transfacial routes described to approach condylar process fractures are preauricular, retromandibular, high submandibular, and their various modifications. The selection of a specific surgical approach mainly depends on the level of condylar fracture, displacement/dislocation of the proximal segment and time elapsed from the date of trauma. Not too many studies proclaim a unanimous consensus on "gold standard" approaches for particular levels of fracture. Aim: This study was conducted with the aim to lay down guidelines for determining the ideal surgical approach for treating different condylar fractures based on different clinical situations. Methodology: This prospective study was conducted on 60 patients that underwent open reduction internal fixation of condylar fractures according to preset study design. Inclusion criteria were fracture displacement more than 10 degrees, dislocation, shortening of ramal height more than 2 mm. Patients having maxillofacial fractures other than mandible and condylar fractures in edentulous patients were excluded from this study. Results: The risk of facial nerve injury was more in endaural group and parotid fistula was more evident in retromandibular subparotid group but there was no statistical difference between the groups. The surgical scar was inconspicuous in all three groups. Excellent results were achieved in the other parameters such as mouth opening, range of motion, bite force, and occlusion with all the three approaches. Postoperative CT scan showed satisfactory anatomical reduction. Conclusion: This study concludes that the decision-making on the approach to be selected for any particular condylar fracture depends on the level of fracture, presence of fracture dislocation, and time elapsed from the date of trauma.

Simultaneous TMJ Ankylosis Release with Uniplanar Mandibular Distraction Osteogenesis for Correction of Facial Deformity and Obstructive Sleep Apnoea in Growing Patients: A Pilot Study.

Aim: To evaluate the efficacy of simultaneous TMJ ankylosis (TMJA) release with uniplanar mandibular distraction in the management of facial deformity, improvement in function and obstructive sleep apnoea in growing patients. Material and Methods: Ten patients in the age group of 5-15 years with unilateral/bilateral TMJA and mild to moderate OSA and short body length but ramus height within normal limits were treated with simultaneous ankylosis release and uniplanar mandibular distraction osteogenesis. Clinical, radiographic, and OSA parameters were evaluated and followed up for 1 year. Results: Average mandibular body length increased by 16.6 mm, mouth opening by 26.9 mm, SNB angle by 9.53°, pharyngeal airway space by 6.29 mm, chin discrepancy corrected by 5.05 mm, apnoea-Hypopnoea index decreased by 15.9, N┴Pog by 12.27 mm, oxygen saturation (Spo2) by 4.1%, and oxygen desaturation index by 17.89%. All clinical, radiographic, and OSA parameters improved and were statistically significant except for mandibular plane angle and with minimal complications. Conclusion: Simultaneous TMJA release with uniplanar mandibular Distraction osteogenesis may be recommended as the treatment of choice in growing patients with mild to moderate OSA and facial deformity, as it causes simultaneous correction of micrognathia, facial asymmetry, OSA and prevents the need for an additional surgery.

Arthrocentesis Versus Level 1 Arthroscopy in Internal Derangement of Temporomandibular Joint.

Introduction: Internal derangement of the temporomandibular joint is defined as an abnormal position of the articular disc in relation with mandibular condyle and articular eminence presenting as disc displacement with or without reduction. Methodology: This study was conducted on thirty patients diagnosed with Internal derangement of TMJ consisting of 8 males and 22 females averaging 34.6 years. Two groups Conventional Arthrocentesis (Group A) and Level 1 Arthroscopy (Group B) consisted of 15 cases each divided alternately. Clinical evaluation parameters included VAS for pain, maximal interincisal opening, deviation on mouth opening, range of motion including lateral excursion & protrusion movements recorded at 1 week, 1 month & 6 months postoperatively. Wilke's Staging according to MRI findings was recorded preoperatively and 6 months postoperatively. Results: At 6 month follow-up, average reduction in VAS for pain & deviation on mouth opening was 72.43% & 24.73% in Group A and 77.66% & 65.41% in Group B, respectively. Average increase in MIO, right & left excursion & protrusion movements was 29.55%, 31.33%, 20.12% & 32.45% in Group A and 34.94%, 41.37%, 39.29% and 36.51% in Group B, respectively. Improved results were obtained clinically for all Wilke's stages in both groups with more number of patients improving in Group B. Conclusion: On comparing results, improvement was observed in various clinical evaluation parameters of both the groups at 6 months follow-up. However, statistically significant & better results were obtained for the Arthroscopy group.

Bilateral Biplanar Distraction Osteogenesis in Facial Deformity Secondary to Temporomandibular Ankylosis.

Background: The purpose of this single-centre prospective clinical study was to evaluate the correction of severe facial deformity and Obstructive sleep apnoea hypopnoea syndrome (OSAHS) in 22 patients aged from 9 to 42 years (mean 20.09) of bilateral Temporomandibular joint ankylosis. Materials and Methodology: Patients underwent multisegment distraction using external bilateral bidirectional distractors. Facial deformity was evaluated clinically in terms of mouth opening and neck chin angle and cephalometrically in terms of corpus length (gonion-pogonion), ramal height (articulare-gonion), chin deficiency (N perpendicular to Pog and SNB). OSAHS was evaluated through Epworth sleepiness scale, Berlin's questionnaire, pharyngeal airway space, apnoeic hypoapnoeic index, oxygen desaturation index, average arterial oxygen saturation and minimal fall in O2 saturation. Patients were followed up for a period of 13-74 months (mean 28.68). Results: Statistically highly significant results were obtained in all parameters. Complications encountered were pin infection (13.63%), loosening of pins (4.5%), wound dehiscence (9.09%), tooth fracture (4.5%) and parotid fistula (9.09%). Intermediate segment necrosis and vector loss were not observed. Conclusion: This study is a large case series using two corticotomy cuts for external bilateral bidirectional distracters with concomitant neo callous moulding in patients both pre- and post-ankylosis release. It is extremely efficient in correcting mandibular corpal and ramal deficiency as well as improving OSAHS.

Dredging: A conservative surgical approach for treatment of large cystic lesions of the jaws.

Background: Treatment modalities of odontogenic cystic lesions of the jaws range from conservative to radical. "Dredging" may be considered the "middle path" between conservative and radical treatment options. It comprises three entities-decompression, followed by repeated scraping of the lesion, and finally, peripheral ostectomy providing margin clearance but without significant morbidity. Aim: To evaluate the outcome of "dredging" in the management of large cystic lesions of the jaws, without major resections and maintaining normal functions. Methodology: This prospective study was conducted on 30 patients. Inclusion criteria were odontogenic cystic lesions at least 2 cm in size either in the proximity of vital structures or in children with developing tooth germs or so large that upon enucleation, can result in pathological fracture. All underwent decompression followed by dredging performed at every 2 to 3 months intervals. Results: Drastic decrease in size of the lesion as measured on Cone Beam Computed Tomography (CBCT) and new bone formation was evident in all patients. The total Reduction Rate (RR) of the cystic lesions was 88.79% in 9.2 months. RR was highest in Calcifying epithelial odontogenic cyst (CEOC) followed by Unicystic Ameloblastoma (UA), Odontogenic Keratocysts (OKC), Dentigerous cyst (DC), and Radicular Cyst (RC) in CBCT. The mean speed of shrinkage was fastest in CEOC, followed by OKC, UA, RC, and DC after dredging. Shrinkage was higher in patients below 20 years of age (P 0.012) and patients with large cystic lesions (P 0.00447). Conclusion: The results suggest that dredging with regular, long-term follow-up can be a successful treatment method for large cystic lesions in young adults. This method includes the benefits of both conservative and radical treatment methods but lacks the disadvantages of either.

Does an autogenous demineralized dentin (ADDM) graft has the ability to form a new bone?

AIM: This aimed to evaluate a new bone formation and to provide a single-stage treatment, i.e., extraction of tooth followed by autogenous dentin demineralized (ADDM) graft in the same extraction socket (ES) - for adult patients who require tooth extraction. MATERIALS AND METHODS: Two hundred teeth extractions were performed to investigate the efficacy of ADDM graft in the formation of new bone. After demineralization of dentin graft parameters such as exposure of graft, any signs of infections/pus/exudates, pain, and bone density were evaluated. RESULTS: On follow-up, exposure of graft was recorded in five sockets at 1 month and infection was recorded in four sockets. Pain was significantly high at postoperative day 1 and least with 3rd and 6th months. There was a highly significant bone formation (P < 0.01, 0.05) in the ES group at various time intervals, while there were no significant differences in the adjacent bone group. CONCLUSION: Using ADDM graft in providing a single-stage treatment plan, i.e., extraction of tooth followed by autogenous demineralized dentin graft in the same ES in adult patients - is an alternative for the immediate reconstruction of alveolar bone defects to facilitate the future prosthesis. It also saves the cost of other graft materials which are commercially available in market for the patient and also reduces the infective dental waste globally.

Temporomandibular Joint Ankylosis Release: 17 Years of Experience with 521 Joints.

OBJECTIVE: Various surgical techniques to release temporomandibular joint (TMJ) ankylosis have been described in the literature. The purpose of this paper is to report our Institution's experience regarding the post-surgical outcome of different surgical techniques for the release of ankylosis of the TMJ. MATERIALS AND METHODS: The records from our hospital of 386 patients (521 joints) treated for TMJ ankylosis were reviewed. Data analysis included the etiology of TMJ ankylosis, gender distribution, age group, distribution of ankylosis based on location, type, interincisal opening and complications in the perioperative period. RESULTS: Out of 521 joints, 65.02% were unilateral and 73.89% had bony ankylosis. The mean maximal incisal opening preoperative was 5.4 mm (SD 3.63 mm) and at 1-year follow-up was 36.9 mm (SD 3.3 mm). There was no permanent facial nerve paralysis. However, transient facial nerve paresis was 14.78%. There was an overall recurrence rate of 8.82%. CONCLUSION: We conclude that after TMJ ankylosis release with interpositional arthroplasty, reconstruction of the RCU with L ramus osteotomy is the most favorable. This procedure not only causes least complications, but also maintains height of ramus, facilitating surgeries for secondary asymmetry correction.

Buccal Fat Pad-Derived Stem Cells for Repair of Maxillofacial Bony Defects.

AIM: The purpose of this study was to evaluate the use of buccal fat pad-derived stem cells (BFPSCs) as a source for full thickness bone defect repair secondary to pathology in maxilla or mandible. METHODS: Fat-derived stem cells were isolated from buccal fat pad, differentiated into osteocytes in osteogenic medium, and seeded onto human bone defects. Autologous buccal fat pad was harvested and BFPSCs cultured within 4-6 weeks. Bone defects secondary to enucleation of pathologic cyst or tumors were reconstructed with osteogenically differentiated fat-derived stem cells. Hematoxylin and eosin staining, immunohistochemical staining for osteocalcin, alkaline phosphatase and genotypic and phenotypic marker analysis, and histomorphometric measurements of new bone were performed. RESULTS: Maxillofacial bone defects were successfully reconstructed by BFPSCs, which after implantation at an in vivo site yielded faster osseous regeneration. BFPSCs were associated with superior bone density formation, better blending of margins with enhanced bone trabecular formation, well-organized and well-vascularized lamellar bone with Haversian channels and osteocytes resulting in superior functional and cosmetic results with better quality of life and with significant decrease in secondary complications. CONCLUSION: Buccal fat pad is an ideal tool in the hands of an oral and maxillofacial surgeon for tissue engineering and clinical use requiring bone tissue growth and repair, secondary to large osseous defects. This study demonstrates the feasibility of reconstructing bony defects with fat-derived stem cells.

Novel Use of Orbita Plates in Mandibular Body Fractures.

BACKGROUND: Isolated fractures of the mandibular body separate the dentate border and compress lower border when subjected to masticatory forces. This study aims at evaluating the efficacy of two Orbita plates in Champy's osteosynthesis lines along with achieving 3D configuration and preventing trauma to mental foramen. AIMS: (1) To achieve a near 3D configuration by fixing the terminal parts of both plates in contact with each other; (2) to preserve the mental nerve within the ellipse created by two Orbita plates; and (3) to prevent damage to the root apices from the upper plate. MATERIALS AND METHODS: This study was performed on 20 patients with mandible body fracture through the mental foramina. With the intraoral vestibular approach, two Orbita miniplates were fixed in Champy's osteosynthesis lines. A geometrically closed quadrangular relationship was achieved in the shape of an ellipse, with the mental nerve emerging from it. RESULTS: Fracture healing was optimum in all the cases along with satisfactory occlusion. Postoperative intermaxillary fixation was not required. Mental nerve function impairment was insignificant. CONCLUSION: This served to achieve satisfactory functional outcomes in patients with mandible body fracture without injury to roots and along with achieving a geometrically close quadrangular relationship even where 3D miniplates cannot be placed.

Conservative Management of Unicystic Ameloblastoma in Young Patients: A Prospective Single-Center Trial and Review of Literature.

AIMS: The study intends to evaluate the clinical outcome of treating young patients of unicystic ameloblastoma, by various conservative treatment modalities such as marsupialization, enucleation with bone curettage and aid in establishing sound treatment guidelines. MATERIALS AND METHODS: A case series of fifteen patients is presented of unicystic ameloblastoma, who presented to our Department over the past 6 years (2010-2015) and conservative method of treatment elected in all the patients. Also, a methodical literature review of studies discussing treatment of unicystic ameloblastoma in young age group (<20 years) patients over the last 15 years from 2001 to 2015 is added. RESULTS: Faster osseous regeneration after conservative treatment was noted, owing to the young age and growth potential. Over a mean follow-up of 4 years, uneventful secondary healing, no clinical or radiographic evidence of recurrence and no apparent deformity were noted in any of the cases. CONCLUSION: Unicystic ameloblastoma is a benign, locally invasive odontogenic neoplasm of young age which can develop during the stage of tooth formation and hence its early inception and vast proliferation is not uncommon in this age group, due to which it can grow into a huge lesion causing significant morbidity. Conservative surgical management may be a viable option to reduce morbidity and increase the probability of uneventful secondary healing and bone regeneration in the younger population.

Have Smartphones Contributed in the Clinical Progress of Oral and Maxillofacial Surgery?

BACKGROUND: Dental surgeons who encounter complex situations, such as those in unscheduled care, often have limited resources to provide a structured and specialty care. Therefore, there is always a need for cost-effective, easy to handle, easy to carry "Smartphones". OBJECTIVE: The purpose of this paper was to undertake a review of literature on "Smartphone in Oral and Maxillofacial Surgery" online data-base and discuss the case series with emphasis on the role of attending dental surgeon and the maxillofacial surgeon. MATERIALS AND METHODS: The available literature relevant to oral and maxillofacial surgery in online data-base of the United States National Library of Medicine: PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) was searched. The inclusion criterion was to review the published clinical papers, abstracts and evidence based reviews on 'Uses of Smartphone in Oral and Maxillofacial Surgery'. RESULTS: Six articles were found with the search term "Smartphone in Oral and Maxillofacial Surgery" in the literature searched. Five articles met the inclusion criteria for the study. The relevant data was extracted, tabulated, and reviewed to draw evidence-based conclusions for uses of smartphone in oral and maxillofacial surgery. CONCLUSION: Utilization of smartphones in oral and maxillofacial surgery facilitate in differential diagnosis, treatment, follow up, prevention of the disease further and thereby improve the quality of patient care without requiring the presence of the maxillofacial surgeon in remote areas.

Comparative Evaluation of Vital Parameters During Third Molar Surgery Under Local Anaesthesia with and without Sedative Agents.

AIMS: To compare vital parameters; operator's comfort; and patient's satisfaction during impacted third molar removal under local anaesthesia, with or without sedative agents. MATERIALS AND METHODS: Ninety patients undergoing elective third molar surgery were randomly divided into three groups of 30 each: Group A received propofol along with local anaesthesia; Group B received midazolam along with local anaesthesia and Group C received local anaesthesia alone. After the local anaesthesia, with or without sedative agents, the impacted third molars were removed in Operation Theater. RESULTS: Group A clearly showed advantages over Group B & C on all the parameters that we have selected. CONCLUSION: Even though the cost of propofol is high, suitable operating conditions, faster onset of sedation, rapid recovery, and minimal side effects support the use of this drug for conscious sedation for third molar surgery.

Orofacial tubercular lesions.

AIM: The aim of this study was to evaluate the clinical characteristics of orofacial lesions like ulcer, swelling, discharge (with or without fistulae), nodules (tubercles), granulomatous growth, induration, diffuse inflammation, and extraction socket involvement in an Indian population through the case reports and review of literature. MATERIAL AND METHODS: Four case reports are presented of patients who had orofacial lesions which turned out to be tuberculous. The diagnosis of tuberculosis was possible because it was kept high on the list of differential diagnosis of orofacial lesions. In our study, we used the following clinical criteria: 1) Suspicious lymph nodes should be biopsied. 2) Excision of non-healing, fistulous, or non-responsive lesions should be considered for biopsy. 3) Histopathological evidence of granulomatous inflammation with epithelioid cells and Langhan's giant cells or acid-fast bacilli should on Ziehl-Neelsen staining. 4) The patients' medical records were reviewed for details relating to presenting signs and symptoms, site and appearance of the lesions, chest x-ray findings, and sputum smear and tuberculosis culture results. RESULTS: In all cases, the patients were prescribed antituberculosis therapy (ATT) by the physician. Strict follow-up was done to ensure completion of intensive phase therapy and both oral as well as pulmonary lesions were resolved. CONCLUSION: Dentists and physicians treating orofacial lesions should be alert to the possibility of orofacial tuberculosis. Medical history should be taken very carefully and lymph node biopsy as well as other radiological and microbiological investigations should be carried out to rule out oral tuberculosis. Antituberculous therapy leads to successful resolution of the orofacial lesions.